Hearing Loss: Impact, Policy Implications, and Future Directions

By: Margaret I. Wallhagen, PhD, GNP-BC, AGSF, FGSA, FAAN

Professor and Interim Chair, Department of Physiological Nursing
Director, UCSF John A. Hartford Center of Gerontological Nursing Excellence
Nurse Senior Scholar, San Francisco VA Quality Scholars Fellowship Program

Introduction
Our senses serve as a window to the world, allowing access to essential information that
underpins daily functioning. As one sensory domain, hearing is critical to an individual’s ability to
communicate, interact with others, perceive dangers, and feel connected to the environment (Dalton et
al. 2003; Kochkin & Rogin, 2000; National Council on Aging [NCOA], 1998). Loss of hearing is found to
impact quality of life and relationships with family and friends (Ciorba, Bianchini, Pelucchi, & Pastore,
2012; Dalton et al, 2003; Kochkin & Rogin, 2000; Kramer, Allessie, Dondorp, Zekveld, & Kapteyn, 2005);
the ability to remain engaged in preferred activities and work (Goldstein, 2011; Kochkin, 2007b, 2010;
NCOA, 1998; Stam, Kostense, Festen, & Kramer, 2013); cognitive and physical functioning (Genther,
Frick, Chen, Betz, & Lin, 2013; Lin, 2011; Lin & Ferrucci, 2013; Valentijn et al., 2007); and the ability to
understand health care instructions (Pacala & Yueh, 2012; Pope, Gallun, & Kampel, 2013).
Because hearing loss affects over 50% of persons age 65 and older with its prevalence increasing
with age, it must be considered a significant health care concern (Bainbridge & Wallhagen, 2014). Yet
many individuals who might benefit from amplification do not use it or delay seeking assistance for over
five years, and most health care practitioners neither screen for hearing loss nor refer for follow-up
evaluations (Kochkin, 2004; National Institute on Deafness and Other Communication Disorders
[NIDCD], 2010a; Wallhagen & Pettingill, 2008). The purpose of this issues brief is to highlight: the
significance of hearing loss in older adults, including its impact on health and safety; the barriers to
treatment; and potential future directions and options. The emphasis is on the implications the
identified issues have for Medicare and Social Security.

Impact of hearing loss on societal engagement

Hearing is a complex, multi-process sense and ultimately occurs when the brain receives and
interprets sounds from the environment (Bagai, Thavendiranathan, & Deksky, 2006). This, however,
necessitates adequate and accurate receipt of sound signals. Age related hearing loss, or Presbycusis, is
a form of sensoryneural hearing loss that generally starts with a decrease in the ability to hear high

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frequency sounds (Bagai et al., 2006). Consonants, such as “t” or “s”, are high frequency sounds while
vowels, such as “a” or “i”, are low frequency sounds. Consonants make language understandable; they
assist in differentiating words such as “dime” and “time” or “sing” and “thing”. On the other hand, low
frequency sounds are more audible than high frequency sounds. Thus, persons with age related hearing
loss often note that others “mumble” or don’t enunciate clearly or state that they can hear but don’t
understand. This emphasizes a key point - hearing loss is not a decrease in sound as might be
experienced when wearing ear plugs but a distortion of sound transmission.
Understanding in the presence of background noise, in settings with significant reverberations,
and when individuals speak with an accent are especially problematic. As hearing loss progresses, low
frequency audibility is often affected. These changes have significant implications for an individual’s
ability to participate in work or other social activities and increase the risk of an individual
misinterpreting what is perceived.

Significance and Impact of Hearing Loss

Impact on work and societal-related activities

Hearing loss impacts an individual’s work life in several inter-related ways – it makes
participating in the work environment challenging, especially if the work entails meetings, using the
phone, or communicating with clients and other personnel (Boulton, 2013; Ross, 2011). At the same
time, about 60% of those with some hearing loss are in a work or educational setting (Ross, 2011).
Although there are adaptations that can be made to facilitate continued work in these settings,
individuals may not wish to acknowledge their loss because of concerns about keeping their job. This is
not an unrealistic concern; data support that persons with hearing loss earn less than those without
hearing loss, are more likely to be unemployed, and experience work discrimination (Kochkin, 2010;
Bowe, McMahon, Chang, & Louvi, 2005; McMahon, Kifley, Rochtchina, Newall, & Mitchell, 2008). For
example, in a survey of more than 40,000 households, Kochkin (2010) found a $14,100 income
differential between subjects with mild vs. severe hearing loss, and that individuals with untreated
hearing loss could lose upwards of $30,000 annually.
Occupations that involve the need to hear signals and directions in difficult situations, such as
firefighters or security personnel, may be especially impacted and data support that individuals in these
roles may be concerned about acknowledging the loss or using adaptive devises because they risk being
released from service (Goldstein, 2011; Ross, 2011; Stam et al., 2013). While few data are available to

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accurately quantify the negative impact of hearing loss on earning capacity, especially after the age of
65, an early study estimated that the cost per person of obtaining a severe or profound hearing loss at
age 65 years or older was associated with lifetime costs of $43,000 (Mohr et al. 2000). Those who
acquired their hearing loss before retirement were estimated to earn only 50% to 70% of what their
non–hearing-impaired peers would earn, thus losing between $220,000 and $440,000 in earnings over
their working life, depending in part on the age of onset of the hearing loss. These estimates were partly
based on lower workforce participation and reduced wages as compared with those without this degree
of hearing loss. Cost estimates for older adults included medical costs such as hearing aids and health
care visits but did not include possible costs related to assistive living expenses.
Work place discrimination has far reaching implications for older persons. First, the negative
earning potential during key years of productivity influence both retirement benefits and contributions
to Social Security (Social Security Administration, 2013). Second, with increasing longevity, reduced
savings from the recession, and pressures to increase the retirement age at which one qualifies for full
Social Security benefits, older adults are remaining in the work force longer (Purcell, 2007). Hearing loss
reduces their capacity to do so and remain productive. Continued employment is positive because it
both maintains on-going contributions to Social Security and creates less demand on current Social
Security payments.
In addition to impacting work capacity, hearing loss influences an individual’s involvement in
volunteer activities because of difficulty with communication. Volunteerism has been shown to
influence health and well-being in many individuals but can also provide a societal benefit by allowing
older retired individuals to continue to utilize their skills and knowledge to benefit a range of services
(Butrica, Johnson, & Zedlewshi, 2009; Jenkinsen et al., 2013; Poulin et al., 2013).

Impact of hearing loss on health and well-being

Hearing loss has been shown to influence health and well-being in multiple ways and across
multiple domains. Although not mutually exclusive, areas of noted concern include the impact of
hearing loss on psychosocial and physical functioning, safety, and personal relationships.

Hearing loss and safety: Age-related hearing loss influences an individual’s ability to hear warning signals
such as sirens, smoke alarms, disaster warnings, on-coming cars, and phones. Escaping from hotels and
other locations can be delayed when warnings go unheard (FEMA, 1999). In large scale disasters, those
with hearing loss may not be aware of or able to understand warnings and may need specific types of

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adaptive information. Of note, a kit has been developed that specifically focuses on persons with
hearing loss but has not been studied for its impact and it does not yet appear to have wide spread
distribution (Go/Stay/Kit, 2013). Importantly, hearing loss can be a factor in child safety when older
persons serve as childcare resources for their families (Kochkin, 2007c) and either do not hear a safety
warning or do not hear the child’s cry for help. Similarly, driving or walking safely can be affected when
individuals do not hear on-coming cars (Hickson, Wood, Chaparro, Lacherez, & Marszalek, 2010).
An additional safety concern relates to its impact on health and health outcomes. Many older
persons with hearing loss misunderstand or misinterpret what is said. Although not well studied, these
misinterpretations can affect communication within health care settings and in transitions between
health care settings. Hearing loss can also influence diagnostic accuracy and individuals with hearing loss
are sometimes thought to have cognitive impairment when they do not respond or respond
inappropriately to questions. Recent data support the lack of recall after discharge of information
provided in an acute care setting (Engel et al., 2012; Sanderson, Thompson, Brown, Tucker, & Bittner,
2009). While hearing acuity and the effects of hearing loss on this lack of recall was not explored, recent
data document the impact of hospital noise on recall and understanding (Pope et al., 2013) and suggest
that hearing loss impacts the recall of complex medication information (DiDonato, Surprenant, Neath,
2013, poster). Data are needed on the ways in which interventions can facilitate communication in
ways so as to promote understanding of and adherence to health care regimens. Several individual
Hearing Loss Association State Chapters have created hospital kits that individuals can use when
entering a health care system but, although most Chapters are willing to share the kits, they currently
have not been widely distributed or studied (e.g. http://www.swedish.org/patient-visitor-
info/accessibility/printable-communication-aids).

Hearing loss and health: A range of studies have documented the psychosocial and physiological impact
of hearing loss although more data are available on its psychosocial impact with studies often done
within the context of an audiometric assessment and hearing aid benefit evaluation. However, whether
assessed using audiometry or self-report, hearing impairment has been consistently associated with
lower self-reported physical functioning (for example, Dalton et al., 2003; Strawbridge, Wallhagen,
Shema, & Kaplan, 2000), and lower levels of reported quality of life (Dalton et al., 2003; Chia et al., 2007;
Kochkin & Rogin, 2000), although the latter is more strongly related to specific measures of hearing
related activities (Chou, Dana, Bougatsos, Fleming, & Beil, 2011). In the study by Wallhagen and
colleagues (2000), data from the Alameda County Study were used to explore the impact of self-

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reported hearing difficulty, even with a hearing aid; hearing and understanding words in a normal
conversation; hearing words clearly over the telephone; and hearing well enough to carry on a
conversation in a noisy room. Findings were divided into three categories: no hearing impairment, a
little hearing impairment, and moderate or more hearing impairment. Compared with those reporting
no impairment, physical functioning, mental health, and social functioning decreased in a dose-response
pattern for those with progressive levels of hearing impairment. Hearing loss has also been associated
with an increased incidence of falls (Lin & Ferrucci, 2013) and hospital admissions (Genther et al., 2013),
each of which can lead to further disability and health care utilization.
Additional data, although still generally from self-reported data, support the adverse impact of
difficulty hearing on physical functioning as well as mortality and strengthen the association by
documenting its impact internationally. Yamada and colleagues (2011) studied the impact of self-
reported hearing difficulty across three years in a Japanese cohort of older adults (≥65) and found that
those reporting a lot of difficulty hearing, even with a hearing aid, had a greater risk of dying or
becoming dependent in activities of daily living than those reporting no difficulty hearing. In a study
using data from several large longitudinal data bases in Australia, Lopez and colleagues (2011)
investigated the impact of both self-reported vision and hearing impairment in older adults aged 76-81
years of age across approximately six years. Those reporting greater levels of hearing impairment found
an increased risk for falls as well as for declines in scores on the physical and mental components of the
SF-36 for both men and women. Finally, Öberg and colleagues (2012) investigated self-reported hearing
difficulties as well as the use of hearing aids and related outcomes and their relationship to
demographic, cognitive, psychosocial, and health variables in persons 85 years of age and older in
Sweden. They used two self-reported items on hearing difficulty with four response categories but
without “with or without a hearing aid” as part of the question. Those with a score of three or more
were considered to have hearing impairment. Participants who reported hearing difficulty but who did
not have hearing aids were found to have worse general health mental health. Of note in this study,
those who did use hearing aids were found to benefit from their use. In fact, the authors noted that,
when used, their hearing aid outcomes were similar to those of a younger group.
Although hearing loss was noted to be associated with altered cognitive functioning years ago
(Lindenberger & Baltes, 1994; Baltes & Lindenberger,1997), this relationship has become a greater focus
of concern with more recent data linking hearing loss with both self-reported lower cognitive
functioning and dementia (Lin, 2011; Lin, Metter, O’Brien, Resnick, Zonderman, & Ferrucci, 2011;
Wallhagen, Strawbridge, Shema, 2008). In a cross-sectional analysis of the Baltimore Longitudinal Study

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of Aging (BLSA), Lin, Ferrucci, Metter and colleagues (2011) investigated the association between
hearing impairment, measured audiometrically and calculated as a pure tone average (PTA) across 0.5,
1, 2, and 4 kHz, and memory and executive functioning. Higher levels of hearing loss were significantly
associated with lower scores on measures of mental status, memory, and executive function. Similarly,
in a study using the National Health and Nutrition Survey data, Lin (2011) found an association between
audiometrically assessed hearing loss and lower scores on the Digit Symbol Substitution Test, a measure
of executive function and psychomotor speed. Finally, in a longitudinal analysis of data of persons
participating in the BLSA who were dementia free in 1990 or 1994, Lin and Colleagues (Lin, Metter, et al,
2011) found that hearing impairment, assessed audiometrically, was associated with increased odds of
incident dementia. In these analyses, increasing levels of hearing impairment (mild, moderate or severe)
were associated with increasingly higher odds. Given the cost of care for persons with dementia and the
increasing prevalence of cognitive impairment with age, identifying risk factors that might be amenable
to intervention is of significant concern. Although the data linking hearing loss and cognitive decline and
dementia are still associational and no studies are available supporting the beneficial effects of hearing
aids, further studies are warranted, especially to assess whether early intervention before hearing loss
becomes significant may be beneficial.
Remaining engaged in activities has been associated with what has been termed “successful
aging” (Havinghurst, 1961; Rowe and Kahn, 1997; Ryff, 1989) and, as noted earlier, hearing loss directly
impacts the ability to easily and effectively stay involved in meaningful activities and personal
relationships. Personal relationships may be especially affected. Thus, studies have documented the
impact of hearing loss on spouses (Kramer et al., 2005; Wallhagen, Strawbridge, Shema, Kaplan, 2004)
although the effects may be more important for wives than for men (Wallhagen et al., 2004; Ask, Krog,
& Tambs, 2010). Additionally, although there were several early studies suggesting a negative impact of
hearing loss on a caregiver (Kuzuya & Hirakawa, 2006), no recent studies appear to have addressed this
concern. Such studies may be important to assess the effects of interventions to improve hearing and
communication on subsequent admission to a long-term care setting.
The cost of hearing loss to the health care system and society in terms of lost productivity,
injury, and health care utilization has not been well defined but data suggest that it may be significant
(Mohr et al., 2000). Greater and more effective use of the newer and more refined hearing aids along
with the use of aural rehabilitation strategies could be effective in reducing health care and societal
costs as well as the personal costs of hearing loss for older adults and their families.

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 Barriers to the Treatment of Hearing Loss

Given its significant impact, it might be assumed that older adults and health care practitioners
would identify hearing loss as an essential health care concern. However, multiple barriers minimize the
extent and effective use of hearing health care services. These include: the cost of hearing aids; lack of
coverage of hearing health care services and hearing aids by Medicare and most other forms of
insurance; and lack of agreement across the hearing services community about payment approaches.
Barriers also include the stigma associated with hearing loss; the fact that hearing loss comes on slowly
which limits initial awareness; lack of knowledge of alternatives to hearing aids; lack of knowledge of
and appreciation for hearing loss by health care practitioners and lack of screening; and the
prioritization of other health-related concerns by both individuals with hearing loss and their health care
providers.

Cost, lack of coverage, bundled services, and inter-professional disagreement about approaches to
covering hearing health care services
Three major factors determine whether Medicare will cover a service. It has to fall within a
defined Medicare benefit category, be reasonable and necessary for diagnosis or treatment, and not be
statutorily excluded from coverage. When Medicare was enacted in 1965 it was designed especially to
cover acute illnesses and hospital-related care; hearing health care services were statutorily excluded
(Social Security Act § 1862(a)(1), 1965) unless they were determined to be “medically necessary.”
Although legislation to change Medicare to allow for such services was introduced as early as 1977 when
Claude Pepper submitted H.R. 1127 (1977), this and all subsequent legislation have not made it out of
Committee for consideration by the full House of Representatives. Concerns expressed usually relate to
the costs to Medicare that such services would incur. Unfortunately, for older adults, such lack of
coverage has remained a barrier to access (Knudsen, Oberg, Nielsen, Naylor, & Kramer, 2010; Kochkin,
2007a; NCOA, 1999). Since many other health insurance programs use Medicare as a model for such
coverage, lack of insurance coverage is fairly far reaching. Further, although Medicaid can provide
hearing aid and hearing services coverage, such coverage usually focuses on children. Whether Medicaid
covers hearing services for adults and what those services are remains highly variable across the states
(Kaiser Family Foundation, 2010). In addition, changes that are being considered in several states are
viewed with significant concern by hearing health care professionals who believe that decreases in
payment will force many to stop providing services to persons with this coverage (California State
Controller’s Office, 2012; Lindsey, 2013).

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 Given lack of insurance coverage, hearing aids are often viewed as very costly, especially when
benefits are not perceived as balancing the cost. However, one reason for the cost of hearing aids is that
their cost is often “bundled” in with all hearing health care services, such as the fees associated with the
assessments, fittings and adjustments (Sjoblad & Winslow, 2011; Strom, 2012). Although this allows for
the individual to return for needed alterations that promote appropriate use, persons receiving hearing
aids are often unaware of the extent of the coverage and perceive this as the cost of the hearing aids
themselves. Further, adapting to hearing aids requires time because the individual has to relearn how to
listen and get used to sounds that have not been heard for a long time. Aural rehabilitation is designed
to assist individuals acquire these skills and is recommended to be included in the audiologic services
provided but is often either not provided or provided at a minimal level (Sweetow, & Sabes, 2010). Lack
of adequate assistance in adapting to the hearing aids and re-learning how to listen and hear can
minimize the real and perceived benefits of hearing aids and discourage their use.
At the same time, professionals providing hearing services are generally not supportive of
changing Medicare to cover hearing aids, and they differ across professional groups (Table 1,
Organizations/Associations) regarding ways to address the cost of hearing services (see Table 2 for
synopsis). The one agreed upon approach is the use of a tax credit for hearing aid purchase. The
various options are further developed below.

Stigma, slow onset, and lack of screening

Hearing loss tends to come on slowly so that individuals are often initially unaware of their
hearing loss especially because they continue to hear low-frequency sounds and thus feel others
mumble or don’t enunciate clearly (NIDCD, 2010b). They can also compensate in ways that initially
minimize the impact by asking others to repeat, avoiding difficult listening situations, and filling in what
is said based on context (Andersson, Melin, Lindberg, & Berit, 1996; Kochin & Rogin, 2000). This can
lead to misunderstandings, some of which may go unrecognized by the individual him or herself.
Spouses or partners often contribute to the individual’s ability to underappreciate the loss by providing
the missed information and adapting to the individual’s needs (Scarinci, Worrall, & Hickson, 2008).
Further, the fact that hearing loss and hearing aids are also often perceived as stigmatizing and are
associated with being old and disabled (Southhall, Gagne, Jennings, 2010; Kochkin & Rogin, 2000;
Wallhagen, 2010), contributes to the denial of hearing loss, minimization of its impact, and delay of
seeking help.

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 Screening for hearing loss in primary care settings during routine exams would promote
awareness of hearing loss but there is a general lack of knowledge of and appreciation of hearing loss by
health care practitioners and routine screening is rarely accomplished (Cohen, Labadie, & Haynes, 2005;
Kochkin, 2005; Wallhagen & Pettingill, 2008). Further, practitioners usually prioritize other health-
related concerns over hearing loss and thus rarely address it or refer patients for follow-up (Cohen et al.,
2005). Because it is an invisible problem and individual face-to-face conversations are the easiest for
individuals with hearing loss to manage, problems with hearing are not routinely identified during health
exams unless the loss is significant.

Opportunities and Future Directions

Although there are significant barriers to the incorporation of hearing health care services into
general practice and to the promotion of better utilization of those services that are available, the time
may be right for significant progress to be made. First, the increasing numbers of “baby boomers”
becoming eligible for Medicare are more technology savvy than prior generations (American Association
of Retired Persons, 2009) and may significantly increase the demand for hearing services. Second, the
need for individuals to remain in the work force longer and to continue to contribute to both Social
Security and Medicare emphasizes the need to assure that these individuals can remain actively
engaged Purcell 2007), which in turn requires adequate hearing. Third, hearing aid technology and other
assistive listening devices have become much more sophisticated, allowing for better matching between
the hearing needs of a given individual and the resources available (Kaplan-Neeman, Muchnik,
Hildesheimer, & Henkin, 2012). Finally, a range of possible payment options can be considered to
address the concerns of the various stakeholders involved, including relatively low-cost environmental
modifications. These are outlined further below.

Hearing aid tax credit

Most professional and consumer organizations support a bill that has been introduced to
provide a tax credit for the purposes of buying a hearing aid (H.R. 1317, 2013; S. 1694, 2013; Hearing Aid
Assistance Tax Credit Act, sponsored by Representative Latham, R-IA and Senator Harkin, D-IA). This has
generally been limited to small amounts, such as $500, and is further restricted to those with incomes of
less than $200,000. This tax credit, however, does not address the actual cost of the hearing aid,
improve the services offered, or assist those who currently do not pay taxes. If an “earned income tax”
component was added it would broaden the range of persons who might benefit but the actual need

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addressed is small. This legislation, which does not alter the current service delivery model or address
the cost of the hearing aid or hearing services, is supported by practitioners in the hearing specialties.

Remove the statutory denial of services from Medicare

Legislation designed to amend Title XVIII of the Social Security Act to cover hearing aids and
hearing services, such as those introduced in 2009 by Senator Sherrod Brown (D-OH) and Representative
Gus Bilirakis (D-FL) (S. 1837, 2009; H.R. 504, 2009; Medicare Hearing Enhancement and Auditory
Rehabilitation [HEAR] Act), and one recently introduced by Representative Matt Cartwright (D-PA) (H.R.
3150, 2013, Help Extend Auditory Relief [HEAR] Act), could be reconsidered but would need to be
accompanied by a significant effort to promote their passage. Given prior experience, chances of
passage in the current health care environment are unlikely, given concerns about cost. In fact, the
Govtrac.us web site’s prognosis for the H.R. 3150 was “0% change of being enacted”
(https://www.govtrack.us/congress/bills/113/hr3150). Such bills are also generally opposed by most of
the hearing specialty organizations because of concerns about the limitations Medicare could place on
their ability to cover the cost of their services.
An alternative is to support a bill recently introduced by Representative Bilirakis (H.R. 2330,
2013; Medicare Services Audiology Enhancement Act). This piece of legislation would change Medicare
law to allow coverage of hearing assessments and treatments by audiologists. Under current law,
Medicare can only reimburse audiologists for diagnostic assessments and not for the treatment services
they provide, even though the services are reimbursed when provided by other Medicare practitioners.
This bill is supported by the American Speech-Language-Hearing Association (ASHA) and the American
Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), which is composed of physicians
(Kirkwood, 2013).
Coverage of rehabilitative services could potentially minimize the need for “bundling” of costs
and lead to greater transparency in the cost of a hearing aid. It could also promote greater attention to
the provision of aural rehabilitation that can enhance adjustment to hearing loss, the development of
better listening and communication skills, and the appropriate use of and adaptation to hearing aids
(http://www.asha.org/public/hearing/Adult-Aural-Rehabilitation). Aural rehabilitation should be viewed
as an essential component of a comprehensive hearing health care service. Other hearing health care
specialists organizations, such as American Audiology Association and the Association of Doctors of
Audiology, are currently not in favor of this bill because it preserves the need for an individual to have a
referral from a physician and is perceived as not allowing them to “op-out” of Medicare assignment,

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thus preventing them from billing over the amount allocated by Medicare (Kirkwood, 2013). The
current Medicare coverage is perceived as inadequate. Amendments to the bill could take these
demands into consideration if there was a requirement that the consumer be made aware of the
potential charges and signs a waiver, but this would not necessarily encourage lower hearing aid
charges. ENT physicians, however, do not support direct access and wish to maintain the referral
provision. The bill has not moved out of Committee.
The Federal Employees Health Benefits Program mandates that health insurance companies
bidding to be included as an option provide coverage for hearing health care services but these benefits
vary widely as there is not a standard amount (Foehl, 2008). Unless individuals consider hearing loss
when looking for a health plan there will be minimal pressure to expand coverage and promote the use
of hearing health care services. Similarly, although Medicare Advantage plans sometimes cover hearing
health care services, there are no standards (Shanor, 2013). However, mandating some form of
coverage but providing flexibility might encourage competition and a broader range of options and
might be acceptable to a wider group of hearing professionals. Given the changes occurring with the
Affordable Health Care Act, it may be helpful to use data on the effectiveness or constraints of the
Federal Employees plan to explore flexible options to inform approaches to enhancing the ACA,
including adding hearing health care services to the list of essential health care benefits.

Clarify the cost of hearing health care services and support new models of care
Greater cost transparency could be achieved by the unbundling of fees. This approach has been
taken by a number of audiologists and promoted by several hearing specialist organizations (Sjoblad &
Winslow Warren, 2011; Sweetow, 2009a, 2009b). While this may not initially lead to lower costs,
individuals and families would be more aware of what their payments covered and could purchase
“packages” that might fit their needs. There is concern that this could promote less use of services
needed to adjust and refine the fit of the hearing aid because this would entail an additional cost.
However, it could encourage a greater focus on education about hearing loss and why adjustments and
aural rehabilitation are needed. It also might further encourage the development of more cost effective
models of care. These models, designed to allow individuals to obtain the least expensive hearing aids to
meet their needs, are mainly focused on persons with mild or moderate hearing loss. Examples of these
programs include those that allow individuals to assess their hearing loss on line and order pre-selected
hearing aids; to submit hearing evaluations and get hearing aids by mail; or to have access to low cost

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hearing aids initially designed to provide less expensive options for countries with fewer resources, such
as Project Impact, (www.project-impact.net).
It is not clear how the programs just discussed will assist those with more complex types of
hearing loss or who need greater amplification. What is important to monitor, and is of concern to most
hearing health care specialist, is whether such services lead to the under identification of other serious
otologic problems. Further, if hearing devices are not adjusted to the type of hearing loss individuals are
experiencing, they may not use them and become even more resistant to additional assessments or the
use of hearing aids. Given the extensive range of technology available and the ability of hearing
professionals to customize the amplification to fit the individuals’ hearing loss, further study is needed
about the persons who best benefit from various levels of hearing technology. In any case, hearing aids
are rarely the solution by themselves, especially because their effectiveness is affected by surrounding
environmental sounds, the acoustics of the room, and the distance of the speaker from the person with
hearing loss (Martin & Clark, 2000). Additional assistive listening technology is often needed to promote
a better signal to noise ratio in order to facilitate hearing. That is, the emphasis is on enhancing the
strength or loudness of the sound one desires to hear in comparison to any other interfering or
background sound. Various ssistive listening devices are now available that, although not falling within
the category of hearing aids and thus not regulated by the FDA, can be used to facilitate hearing. These
include a variety of personal amplifiers as well as aps designed for smart phones.

Promote hearing loss as a health concern

Another strategy is to promote hearing loss as a public health issue and disseminate information
to enhance awareness of the significance of hearing loss, its impact and strategies for treatment that
include alternatives to hearing aids. Although age-related hearing loss is extremely common, there is a
pervasive lack of awareness of and knowledge about hearing loss and approaches to its treatment
(Agrawal et al., 2008; Bagai et al., 2006; Boulton, 2013; Chu et al., 2011; Cohen et al., 2005; Kochkin,
2005). Because it is not addressed in routine health evaluations, many older adults, as well as
professionals, attribute hearing loss to normal aging rather than seeing it as a condition that influences a
range of psychosocial and physical health concerns (Kochkin, 1999; NCOA, 1999; Wallhagen & Pettengill,
2008; Williamson & Fried, 1996). A broad-based public information initiative designed and implemented
by an inter-professional and consumer-led group could enhance the visibility of hearing loss and
promote its acceptance as an important health concern. Activities could leverage the awareness
campaign carried out by the Hearing Loss Association of America through its Walk4Hearing events

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(http://hlaa.convio.net) which, while helpful, currently do not receive the visibility necessary to gain the
type of traction needed. Public service announcements and the engagement of local health care
practitioners, along with information disseminated through senior centers and the Aging Network
(www.n4a.org), might also be used to reach the target audience. This educational campaign could
include information on hearing loss, the fact that it involves a distortion of sound, the value of early
treatment, the need to adjust to hearing aids, the need for other assistive devices in addition to hearing
aids in key situations, and the fact that hearing aids are not the only option. Additionally, education
would focus on the importance of hearing to an individual’s safety.
A special initiative could focus specifically on health care practitioners and other health care
workers who know very little about age-related hearing loss. Greater attention needs to be given to
hearing loss in current medical and nursing curricula as well as in both in-person and on-line continuing
education programs. Questions built into competency exams for health care practitioners would
promote greater attention to the need to know such information. However, additional attention must
also be given to persons working in long- term care settings where the prevalence of hearing loss is very
high and the knowledge of the direct care workers on how to care for persons with hearing loss or
manage their hearing aids is extremely lacking (Cohen-Mansfield & Taylor, 2004; Garahan, Waller,
Houghton, Tisdale, & Runge, 1992). The need for this education is emphasized by the awareness that
older persons, especially in long-term care settings, are often misdiagnosed as cognitively impaired
when they are actually hearing impaired (Ohta, Carlin, & Harmon, 1981; Valentjin et al., 2005).

Promote hearing friendly environments

Currently, although the aesthetics and environmental impact of a building, development, or
outdoor entertainment area are the focus of much discussion, minimal consideration is given to the way
in which an environment supports successful communication. However, the promotion of hearing-
friendly environments could have a wide-ranging impact and enhance communication passively for
those with and without hearing loss (Hull, 2011). Considerations should include use of acoustical
designs; incorporation of induction loops into buildings for use by persons with hearing aids that have
telecoils, especially in settings used as public spaces and/or designed to provide entertainment; and
evaluation of designs for unintended consequences in terms of hearing accessibility (too many or too
few reverberations). Such considerations would both facilitate access and enhance awareness of the
importance of hearing. This could involve working with architects and building such design
considerations into their curriculum. In contrast, the current focus is not on maximizing the hearing-

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friendly nature of environments but rather on enhancing their ability to generate noise. Restaurants are
intentionally made so that their acoustics are harsh and maximize reverberations and sound. Sports
arenas are competing to be the noisiest and actively solicit the fans to shout louder and generate more
noise (http://espn.go.com/nfl/story/_/id/10071653/seattle-seahawks-fans-set-stadium-noise-record).
The long-term effects on the participants have not been studied but the emphasis on loudness raises
concerns about the future and the potential for more wide spread noise-induced hearing loss.
Efforts to more fully incorporate induction loops or other assistive listening devices in airports
and captioning for internet access as well as movies need to be encouraged and supported.
Consideration has to be given to the fact that most adult persons with hearing loss do not sign and need
captioning rather than a sign language interpreter to hear. Examples of the benefits of induction loops
for successful hearing can be found from houses of worship
(http://www.youtube.com/watch?v=_3XoVrUjfaY), taxis
(http://www.youtube.com/watch?v=YzvejjipQy0), and subways
(http://www.youtube.com/watch?v=Ahbz0VvlZF0).
In addition, strategies to enhance safety in the event of a disaster need to be further refined and
broadly publicized. Although hotels are supposed to have special rooms and/or services for persons
with disabilities, persons with hearing loss have expressed that these may not be located by the hotel
personnel (personal communication, 2013). For safety in health care settings, hospital kits have been
designed as noted above but have tended to be location specific and not widely distributed or
advertised. This is also true of kits to use in the event of a disaster. The impact of various safety
interventions needs further evaluation and refinement.

Summary
Hearing loss is an extremely common chronic condition, especially in older adults. Although data
support its negative impact on health and well-being, hearing loss is generally underappreciated as an
important health related problem. Multiple barriers minimize the current use of hearing health care
services, including lack of Medicare coverage for hearing aids and aural rehabilitative services. However,
the time may be right for significant progress to be made in addressing hearing loss as a public health
issue and considering a range of policy options that would facilitate the use of hearing health care
services, including aural rehabilitation. Options include legislation that allows Medicare to cover
services, promoting hearing loss as a public health issue, enhancing awareness and knowledge of
hearing loss and its importance, promoting the development of hearing friendly environments,

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supporting new models of hearing health care delivery, and supporting additional research focused on
risk factors for hearing loss and strategies to minimize its impact. Issues addressed by research could
include studies on: the potential contribution of ototoxic medications that are given in low doses across
a long time, such as diuretics, and their interaction with or synergistic effects on age related-hearing
loss; the impact of hearing aids on cognitive and physical functioning; the benefits of alternative forms
of treatment and the use of personal amplifying equipment; how to incorporate cost effective screening
and education into primary care setting to enhance early identification and treatment; and further
documenting the cost to society of hearing loss in older adults. The benefits derived from investment in
these areas could be seen in enhanced well-being as well as cognitive and functional health, longer work
force participation, and greater involvement in volunteer activities.

Page 15
 References
Agrawal, Y, Platz, EA; Niparko, JK. Prevalence of Hearing Loss and Differences by Demographic
Characteristics Among US Adults: Data From the National Health and Nutrition Examination Survey,
1999-2004. Arch Intern Med. 2008;168(14):1522-1530
American Association of Retired Persons. (2009, December). Baby boomers are shaping the future of
technology. Retrieved from http://www.aarp.org/about-aarp/press-center/info-12-
2009/boomer_technology_research.html
Andersson, G., Melin, L., Lindberg, P., & Berit, S. (1996). Elderly hearing-impaired persons’ coping
behavior. International Journal of Behavioral Medicine, 3, 303-320.
Ask, H., Krog, N. H., & Tambs, K. (2010). Impact of hearing impairment on spousal mental health: the
Nord-Trøndelag Health Study. European Journal of Public Health, 20, 271-275. doi:
10.1093/eurpub/ckp176.
Bagai A, Thavendiranathan P, Detsky AS. Does this patient have hearing impairment? JAMA
2006;295(4):416-28.
Bainbridge KE, Wallhagen MI. (2014, In Press) Hearing Loss in an Aging American Population: Extent,
Impact, and Management. Annu Rev Public Health.
Baltes, P. B., & Lindenberger, U. (1997). Emergence of a powerful connection between sensory and
cognitive functions across the adult life span: a new window to the study of cognitive aging?
Psychology and Aging, 12, 12-21. doi: 10.1037/0882-7974.12.1.12
Bouton, K. Shouting Won't Help: Why I--and 50 Million Other Americans--Can't Hear You. Sarah Crichton
Books/Farrar, Straus and Giroux, 2013
Bowe, F., McMahon, B., Chang, T., & Louvi, I. (2005). Workplace discrimination, deafness and hearing
impairment: the national EEOC ADA research project. Work, 25, 19-25.
Butrica, B. A., Johnson, R.W., & Zedlewski, S. R. (2009). Volunteer dynamics of older Americans. Journals
of Gerontology Series B: Psychological Sciences & Social Sciences, 64, 644-655. doi:
10.1093/geronb/gbn042
California State Controller’s Office. (2012, February). Hearing aid re-imbursement analysis. Report to the
California Department of Health Care Services Retrieved from http://www.sco.ca.gov/Files-
EO/S11MPA906.pdf.
Chia, E. M., Wang, J. J., Rochtchina, E., Cumming, R. R., Newall, P., & Mitchell, P. (2007). Hearing
impairment and health-related quality of life: The Blue Mountains Hearing Study. Ear and Hearing,
28, 187-195. doi: 10.1097/AUD.0b013e31803126b6
Chiorba, A., Bianchini, C., Pulucchi, S., & Pastore, A. (2012). The impact of earing loss on the quality of
life of elderly adults. Clinical Investigations in Aging, 7, 159-163. doi: 10.2147/CIA.S26059
Chou, R, Dana, T, Bougatsos, C, Fleming, C and Beil, T. Screening Adults Aged 50 Years or Older for
Hearing Loss: A Review of the Evidence for the U.S. Preventive Services Task Force. Ann Intern Med.
2011; 154:347-355.
Cohen, J., & Taylor, J. W. (2004). Hearing aid use in nursing homes, Part 1: Prevalence rates of hearing
impairment and hearing aid use. Journal of the American Medical Directors Association, 5, 283-286.
doi: 10.1016/S1525-8610(04)70017-1

Page 16
Cohen, S. M., Labadie, R. F., & Haynes, D. S. (2005). Primary care approach to hearing loss: The hidden
disability. Ear, Nose, and Throat Journal, 84(1), 26,29-31,44.
Dalton DS, Cruickshanks KJ, Klein BEK, Klein R, Wiley TL, Nondahl DM. The impact of hearing loss on
quality of life in older adults. Gerontologist 2003; (5):661-8.
DiDonato, R, Surprenant, A, Neath, I (2013, poster) Auditory perceptual and processing enhancements:
How Age-Related Hearing Loss impacts memory of complex medical prescription information. Aging
and Speech Communication, 5th International and Interdisciplinary Research Conference, Indiana
University, Bloomington, October 6-9, 2013
Engel, K. G., Bucklye, B. A., Forth, V. E., McCarthy, D. M., Ellision, E. P., Schmidt, M. J., & Adams, J. G.
(2012). Patient understanding of emergency department discharge instructions: Where are
knowledge deficits greatest? Academic of Emergency Medicine, 19, E1035-E1044. doi:
10.1111/j.1553-2712.2012.01425.x.
Federal Emergency Management Agency. (1999). Fire risk for older adults. Retrieved from
http://www.usfa.fema.gov/downloads/pdf/publications/older.pdf.
Genther, D J, Frick Kevin,D, Chen, D Betz, J, Lin, FR Association of Hearing Loss With Hospitalization and
Burden of Disease in Older Adults; JAMA, June 12, 2013—Vol 309, No. 22; pp 2322-2324
Go/Stay/Kit, 2013. www.gostaykit.com
Foehl, A. (2008, May 6). Hearing benefits upgraded for federal employees. The ASHA Leader
[Newsletter]. Retreived from http://www.asha.org/Publications/leader/2008/080506/080506d.htm
Hearing loss prevalence and management in nursing home residents.
Garahan, M. B., Waller, J. A., Houghton, M., Tisdale, W. A., & Runge, C. F. (1992). Hearing loss
prevalence and management in nursing home residents. Journal of the American Geriatrics Society,
40, 130-134.
Goldstein, J. Ban on Hearing Aids Is Forcing Out Veteran New York City Police Officers. New York Times,
June 19, 2011
Havighurst, R. J. (1961). Successful aging. The Gerontologist, 1, 8-13. doi: 10.1093/geront/1.1.8
Hearing Aid Assistance Tax Credit Act of 2013, H.R. 1317, 113th Cong. (2013).
Hickson, L., Wood, J., Chaparro, A., Lacherez, P., & Marszalek, R. (2010). Hearing impairment affects
older people's ability to drive in the presence of distracters. Journal of the American Geriatric
Society, 58, 1097-1103. doi: 10.1111/j.1532-5415.2010.02880.x
H.R. 1127, 95th Cong. (1977).
Hull RH. Environmental design-An expanding role in hearing rehabilitation for older adults. J
Rehabilitation Research and Development. 2011;48(5):xv-xviii. DOI:10.1682/JRRD.2011.02.0032
Jenkinson, C. E., Dickens, A. P., Jones, K., Thompson-Coon, J., Taylor, R. S., Rogers, M., ..., Richards, S. H.
(2013). Is volunteering a public health intervention? A systematic review and meta-analysis of the
health and survival of volunteers. BMC Public Health, 13, 773. doi: 10.1186/1471-2458-13-773.
Kaiser Family Foundation. (2010). Medicaid benefits: Hearing aids. Retrieved from
http://kff.org/medicaid/state-indicator/hearing-aids/
Kaplan-Neeman, R., Muchnik, C., Hildesheimer, M. & Henkin, Y. (2012). Hearing aid satisfaction and use
in the advanced digital era. The Laryngoscope. 2012 Sep;122, 2029-36. doi: 10.1002/lary.23404

Page 17
Kirkwood, D. H. (2013, June 26). Audiology organizations clash over federal legislative strategies [Web
log post]. Retrieved from http://hearinghealthmatters.org/hearingnewswatch/2013/audiology-
organizations-clash-over-federal-legislative-strategies/
Knudsen, L. V., Oberg, N., Nielsen, C., Naylor, G., & Kramer, S. E. (2010). Factors influencing help seeking,
hearing aid uptake, hearing aid use and satisfaction with hearing aids: A review of the literature.
Trends in Amplification, 14, 127-154. doi: 10.1177/1084713810385712
Kochin, S. (1999). Baby boomers spur growth in potential market, but penetration rate declines. The
Hearing Journal, 52(1), 33-48. Retrieved from the Better Hearing Institute website:
http://www.betterhearing.org/hia/publications/MR34.pdf
Kochkin, S. (2004). BHI physician program found to increase hearing health care use. The Hearing
Journal, 57(8), 27-29. Retrieved from the Better Hearing Institute website:
http://www.betterhearing.org/pdfs/Physician_recommendations_hearing_aids.pdf
Kochkin, S. (2005, July). MarkeTrak VII: Hearing loss population tops 31 million people. The Hearing
Review, 12(7), 16-29. Retrieved from the Better Hearing Institute website:
http://www.betterhearing.org/pdfs/M7_Hearing_loss_trends_2005.pdf
Kochkin, S. (2007a). MarkeTrak VII: Obstacles to adult non-user adoption of hearing aids. The Hearing
Journal, 60(4), 24-50. Retrieved from Better Hearing Institute website:
http://www.betterhearing.org/pdfs/M7_Barriers_to_hearing_aid_usage.pdf
Kochkin, S. (2007b, May). The impact of untreated hearing loss on household income. Retrieve from the
Better Hearing Institute website:
http://www.betterhearing.org/pdfs/M7_Hearing_aids_and_income_2006.pdf
Kochin, S. (2007c, August 30). Child safety often depends on caregiver’s ability to hear [Press release
from the Better Hearing Institute]. Retrieved from
http://www.betterhearing.org/press/news/Hearing_loss_childrens_safety_pr083007.cfm
Kochkin, S. (2010). MarkeTrak VIII: The efficacy of hearing aids in achieving compensation equity in the
workplace. The Hearing Journal, 63(10), 19-26. Retrieved from Better Hearing Institute website:
http://www.betterhearing.org/pdfs/M8_hearing_aids_and_employment_2010.pdf
Kochkin, S., Rogin CM. (2000, January). Quantifying the obvious: The impact of hearing instruments on
quality of life. The Hearing Review. Retrieved from Better Hearing Institute website:
http://www.betterhearing.org/pdfs/MR40.pdf
Kramer, S. E., Allessie, G. H. M., Dondorp, A. W., Zekveld, A. A., & Kapteyn, T. S. (2005). A home
education program for older adults with hearing impairment and their significant others: A
randomized trial evaluating short- ad long-term effects. International Journal of Audiology, 44, 255-
264. doi: 10.1080/14992020500060453
Kuzuya, M., & Hirakawa, Y. (2006). Increased caregiver burden associated with hearing impairment but
not vision impairment in disabled community-dwelling older people in Japan. Journal of the
American Geriatrics Society, 57, 357-358. doi: 10.1111/j.1532-5415.2009.02116.x
Lin, F.R. (2011). Hearing loss and cognition among older adults in the United States. Journal of
Gerontology A Biological Sciences, 66A(10), 1131-1136. Doi:10.1093/Gerona/glr115
Lin, FR, Ferrucci, L. Hearing Loss and Falls Among Older Adults in the United States, Arch Intern Med,
Vol. 172 (No. 4), Feb 27, 2012, pp. 369-371

Page 18
Lin, F. R., Ferrucci, L., Metter, E. J., An, Y., Zonderman, A. B., & Resnick, S. M. (2011, July 4). Hearing Loss
and Cognition in the Baltimore Longitudinal Study of Aging. Neuropsychology. Advance online
publication. doi: 10.1037/a0024238
Lin, F.R., Metter E.J. O’Brien, R.J., Resnick, S.M., Zonderman, A.B., & Ferrucci, L. (2011). Hearing loss and
incident dementia. Archives of Neurology 68(2), 214-220.
Lindenberger, U., & Baltes, P. B. (1994). Sensory functioning and intelligence in old age: A strong
connection. Psychology and Aging, 9, 339-355. doi: 10.1037/0882-7974.9.3.339
Lindsey, H. Texas Medicaid cuts leave hearing healthcare providers at a loss. The Hearing Journal,
October, 66, 10, 20, 22 2013
Martin, F.N & Clark, J.G. (2000). Introduction to Audiology, 7th Ed. Boston: Allyn and Bacon
McMahon, C., Kifley, A., Rochtchina, E., Newall, P., & Mitchell, P. (2008). The contribution of family
history to hearing loss in an older population. Ear and Hearing, 29, 578-584. doi:
10.1097/AUD.0b013e31817349d6
Medicare Hearing Enhancement and Auditory Rehabilitation [HEAR] Act of 2009, H.R. 504, 111th Cong.
(2009).
Medicare Hearing Enhancement and Auditory Rehabilitation [HEAR] Act of 2009, S. 1837, 111th Cong.
(2009).
Medicare Services Audiology Enhancement Act of 2013, H.R. 2330, 113th Cong. (2013).
Mohr PE., Feldman J J., Dunbar, JL., McConkey-Robbins, A, Niparko, JK, Rittenhouse, RK, Skinner, MW
The Societal Costs of Severe to Profound Hearing Loss in the United States. International Journal of
Technology Assessment in Health Care, 16:4 (2000), 1120–1135.
National Council on Aging. (1998). The consequences of Untreated Hearing Loss in Older Americans.
National Council on the Aging. 1998.
http://www.madlerhearing.com/pdfs/ncoa_hearing_summary.pdf.
National Institute on Deafness and Other Communication Disorders. (2010a). Quick statistics. Retrieved
from http://www.nidcd.nih.gov/health/statistics/Pages/quick.aspx.
National Institute on Deafness and Other Communication Disorders. (2010b). Presbycusis. Retrieved
from http://www.nidcd.nih.gov/health/hearing/Pages/presbycusis.aspx.
Ohta, R. J., Carlin, M. F., & Harmon, B. M. (1981). Auditory acuity and performance on the Mental Status
Questionaire in the elderly. Journal of the American Society of Geriatrics, 29ˆ, 476-478.
Pacala, J. T., & Yueh, B. (2012). Hearing deficits in the older patient” “I didn’t notice anything.” Journal of
the American Medical Associaiton, 307, 1185-1194. doi: 10.1001/jama.2012.305
Pope, DS, Gallum, FJ, & Kampel, S. Effect of hospital noise on patients’ ability to hear, understand, and
recall speech. Research in Nursing & Health, 36, 228-241, 2013
Poulin, M. J., Brown, S. L., Ubel, P. A., Smith, D. M., Jankovic, A., & Langa, K. M. (2010). Does a Helping
Hand Mean a Heavy Heart? Helping Behavior and Well-Being Among Spouse Caregivers. Psychology
and Aging, 25, 108.117. doi: 10.1037/a0018064
Purcell, P. (2007). Older workers: Employment and retirement trends (RS30629). Washington, DC:
Congressional Research Service. http://digitalcommons.ilr.cornell.edu/key_workplace/308/
Ross, M. The effects of untreated hearing loss on workplace compensation. The Hearing Loss Magazine,
pp. 26-28. May/June, 2011

Page 19
Rowe, J. W., & Kahn, R. L. (1997). Successful aging. The Gerontologist, 37, 433-440. doi:
10.1093/geront/37.4.433
Ryff, C. D. (1989). Beyond Ponce de Leon and life satisfaction: New directions in quest of successful
ageing. International Journal of Behavioural Development, 12, 35−55. doi:
10.1177/016502548901200102
Sanderson, B. K., Thompson, J., Brown, T. M., Tucker, M. J., & Bittner, V. (2009). Assessing patient recall
of discharge instructions for acute myocardial infarction. Journal for Healthcare Quality, 31, 25-33.
doi: 10.1111/j.1945-1474.2009.00052.x
Scarinci, N., Worrall, L., Hickson, L. (2008). The effect of hearing impairment in older people on the
spouse. International Journal of Audiology, 47, 141-151. doi: 10.1080/1499202701689696
Shanor, N. (2013, July 10). Some Medicare Advantage plans cover hearing aids [Web log post]. Retrieved
from http://imedicare.com/some-medicare-advantage-plans-cover-hearing-aids
Social Security Act, 42 U.S.C. § 1862(1) (1965).
Social Security Administration. (2013). Understanding the benefits. Retrieved from
http://www.ssa.gov/pubs/EN-05-10024.pdf.
Sjoblad, S & Winslow Warren, B. Unbundling: A Way to Make Hearing Aids More Affordable? The
Hearing Loss Magazine, September/October 2011 19-21
Southhall, K., Gagné, J. P., Jennings, M. B. (2010). Stigma: A negative and a positive influence on help-
seeking for adults with acquired hearing loss. International Journal of Audiology, 49, 804-14. doi:
10.3109/14992027.2010.498447
Stam, M., Kostense, P. J., Festen, J. M., & Kramer, S. E. (2013). The relationship hearing status and the
participation in different categories of work: Demographics. Work, 46, 207-219. doi: 10.3233/WOR-
131747
Strawbridge, W. J., Wallhagen, M. I., Shema, S. J., & Kaplan, G. A. (2000). Negative consequences of
hearing impairment in old age: A longitudinal analysis. The Gerontologist, 40, 320-326. doi:
10.1093/geront/40.3.320
Strom, K. The long quest for unbundling hearing services from products (editorial). The Hearing Review,
July, 2012 p. 6.
Sweetow, R. W., & Sabes, J. H. (2010). Aural training and challenges associated with participation and
compliance. Journal of the American Academy of Audiology, 21, 586-593. doi: 10.3766/jaaa.21.9.4
Sweetow, R. (2009a). Hearing aid delivery models, Part 1 of 2. Audiology Today, 21(5), 49-57.
Sweetow, R. (2009b). Hearing aid delivery models, Part 2 of 2. Audiology Today, 21(6), 33-37.
Valentijn, S. A. M., van Boxtel, M. P. J., van Hooren, S. A. H., Bosma, H., Beckers, H. J. M., Ponds, R. W. H.
M., & Jolles, J. (2007). Change in sensory functioning predicts change in cognitive functioning:
Results from a six-year follow-up in the Maastricht Aging Study. Journal of the American Geriatrics
Society, 53, 374-380. doi: 10.1111/j.1532-5415.2005.53152.x
Wallhagen, M. I., & Pettengill, E. (2008). Hearing impairment: Significant but underassessed in primary
care settings. Journal of Gerontological Nursing, 34(2), 36-42. doi: 10.3928/00989134-20080201-12
Wallhagen, M. I., Strawbridge, W. J., & Shema, S. J. (2008). The relationship between hearing
impairment and cognitive function: a 5-year longitudinal study. Research in Gerontological Nursing,
1, 80-86. doi: 10.3928/19404921-20080401-08

Page 20
Wallhagen, M. I., Strawbridge, W. J., Shema, S. J., & Kaplan, G. A. (2004). Impact of self-assessed hearing
loss on a spouse: a longitudinal analysis of couples. Journals of Gerontology Series B: Psychological
Sciences and Social Sciences, 59, S190-S196. doi: 10.1093/geronb/59.3.S190
Williamson, J. D., & Fried, L. P. (1996). Characterization of older adults who attribute functional
decrements to "old age". Journal of the American Geriatrics Society, 44, 1429-34.
Yamada M, Nishiwaki Y, Michikawa T, Takebayashi T Impact of hearing difficulty on dependence in
activities of daily living (ADL) and mortality: a 3-year cohort study of community-dwelling Japanese
older adults. Arch Gerontol Geriatr. 2011 May-Jun; 52(3):245-9. doi: 10.1016/j.archger.2010.04.023.

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